A 2 year old male presents at 9pm to the emergency department with respiratory distress. His parents describe a three day history of rhinorrhoea and coryza. He has notable inspiratory stridor at rest accompanied by tracheal tug and subcostal recession. When he coughs, the sound has a distinct “barking” note.

ANSWER: CROUP

COMMENT: the age and clinical presentation, especially the barking cough, are typical of croup

EMQ 2.

An 8 month old baby presents with her parents. They are concerned that she has not been feeding well over the past 24 hours, and describe a congested nose and dry cough for the previous 3 days. On examination the child has a temperature of 38.1oC, and diffuse fine crepitations throughout both lung fields.

ANSWER: Bronchilitis

COMMENT: a respiratory illness becoming worse on day 3-4 without focal chest signs is typical of bronchiolitis in this age group.

EMQ 3.

A 10 month old child presents with a decreased level of interactivity. His parents say he has not been feeding particularly well. On examination he has a temperature of 39.6oC and a capillary refill of 3 seconds. He has bronchial breath sounds at the left base.

ANSWER: LRTI.

COMMENT: this child, with signs of sepsis, likely has a pneumonia.

EMQ 4.

A 14 month boy is brought to the emergency department by his mother with a persistent dry cough. He is afebrile and otherwise well. On examination he has a polyphonic wheeze with a deeply pitched note confined to the base of his right lung.

ANSWER: swallowed foreign body.

COMMENT: The localisation of the wheeze to the right lower lobe (the termination point of the right main bronchus) is highly suspicious for an aspirated foreign body.

EMQ 5.

A 4 year old boy with a history of eczema presents to the department complaining of difficulty breathing. He has had a dry cough, rhinorrhoea and red eyes for the previous 24 hours. On examination he has a diffuse polyphonic expiratory wheeze throughout both lung fields.

ANSWER: Reactive airways diseaseCOMMENT: this child likely has bronchospasm in response to an intercurrent LRTI. Although he may subsequently acquire a formal diagnosis of asthma, this is his first visit and such a diagnosis should not be made at this time.